What is the management of persistent watery rhinorrhea?

From the Guidelines

To manage persistent watery nasal discharge, the most effective approach is to use nasal saline sprays or rinses 2-3 times daily to flush out mucus and irritants, as supported by a Cochrane review that reported minor improvements in nasal symptom scores with the use of nasal saline 1. This method is recommended as the initial step in managing symptoms, given its low risk of adverse reactions and potential for symptom relief. For additional relief, oral decongestants may be considered, barring any medical contraindications, such as hypertension or anxiety, as they can provide symptomatic relief 1. Topical intranasal steroids may also have a role in managing persistent watery nasal discharge, as they have been found to relieve facial pain and nasal congestion in patients with rhinitis and acute sinusitis, although the magnitude of effect is small and the decision to use them should be based on patient preference 1. Key considerations in managing persistent watery nasal discharge include:

• Identifying and avoiding triggers such as allergens or irritants
• Using saline nasal sprays or rinses 2-3 times daily
• Considering oral decongestants for symptomatic relief, if medically appropriate
• potentially using topical intranasal steroids for their modest clinical benefit, weighing the benefits against the cost and patient preference 1. It is essential to note that if symptoms persist beyond 7-10 days, worsen, or are accompanied by fever, facial pain, or discolored discharge, consultation with a healthcare provider is necessary, as this could indicate sinusitis or another condition requiring different treatment 1.

From the FDA Drug Label

Patients treated with Fluticasone Propionate Nasal Spray, USP, at a dosage of 100 mcg twice daily exhibited statistically significant decreases in TNSS compared with patients treated with vehicle. The relative difference in efficacy with as-needed use as compared to regularly administered doses was not studied Maximum effect may take several days Regular-use patients who have responded may be able to be maintained (after 4 to 7 days) on 100 mcg/day (1 spray in each nostril once daily). The answer to managing persistent watery nasal discharge is to use Fluticasone Propionate Nasal Spray, USP at a dosage of 100 mcg twice daily for optimal effect.

• Key points:
  • Start with a dose of 100 mcg twice daily
  • Maximum effect may take several days
  • Patients may be maintained on 100 mcg/day after 4 to 7 days 2

From the Research

Managing Persistent Watery Nasal Discharge

To manage persistent watery nasal discharge, several treatment options are available, depending on the underlying cause of the condition.

• Allergic Rhinitis: For patients with allergic rhinitis, treatment may include avoiding inciting allergens, using second-generation H1 antihistamines (e.g., cetirizine, fexofenadine, desloratadine, loratadine) or intranasal antihistamines (e.g., azelastine, olopatadine), and intranasal corticosteroids (e.g., fluticasone, triamcinolone, budesonide, mometasone) 3.
• Nonallergic Rhinitis: For patients with nonallergic rhinitis, first-line therapy may consist of an intranasal antihistamine as monotherapy or in combination with an intranasal corticosteroid 3.
• Seasonal Allergic Rhinitis: Fluticasone propionate aqueous nasal spray has been shown to be more effective than loratadine in treating seasonal allergic rhinitis 4.
• Combination Therapy: The combination of fluticasone propionate aqueous nasal spray and loratadine may be more effective than loratadine alone in treating seasonal allergic rhinitis, but the addition of loratadine to fluticasone propionate may not provide significant additional benefits 5.
• Antibiotics: For children with persistent nasal discharge, antibiotics may be effective in reducing the probability of persistence in the short to medium-term, but the benefits appear to be modest and may require treatment of eight children to achieve one additional cure 6.

Treatment Options

The choice of treatment for persistent watery nasal discharge depends on the underlying cause and severity of the condition.

• Intranasal Corticosteroids: Fluticasone propionate aqueous nasal spray has been shown to be effective in treating seasonal allergic rhinitis and may be more effective than oral antihistamines 4, 5, 7.
• Antihistamines: Second-generation H1 antihistamines and intranasal antihistamines may be effective in treating allergic rhinitis, but may not be as effective as intranasal corticosteroids in treating seasonal allergic rhinitis 3, 4, 5.
• Leukotriene Receptor Antagonists: The combination of a histamine1 receptor antagonist and a leukotriene D receptor antagonist may be effective in treating seasonal allergic rhinitis, but may not be as effective as intranasal corticosteroids 7.